Revarsate pleurale

LICHIDELE PLEURALE

• Pleura parietala: circulatia arteriala si venoasa sistemica

( art. intercostale, a. mamara interna a. frenice)

nervi intercostali (senzoriali)

• Pleura viscerala: art. pulmonare,

gg. mediastin post, gg.hilari

fara inervatie senzoriala

• 5-15ml lichid pleural • 0.01ml/kg/h

• 1,5 g proteine/dl • 4500 celule/ml: mezoteliale, monocite, limfocite, granulocite (rare)

- capilarele pleurei parietale, - capilarele pleurei viscerale - cavitatea peritoneala

L

PLEURAL

• Transudate

- modificari hemodinamice:

- pres hidrostatica capilara↑,

- pres osmotica ↓

• Exudate

- permeabilitate capilara ↑

- scaderea drenajului limfatic pleural (20 ×N)

DiagnosticDiagnosticClinic: durere (intercostala, umar)Clinic: durere (intercostala, umar)

tusetuse

dispneedispnee

Frecatura pleuralaFrecatura pleurala

Sindrom lichidian (> 500 ml)Sindrom lichidian (> 500 ml)

vol micvol mic: 3-4 cm post. la baza : 3-4 cm post. la baza hemitorace hemitorace

800 – 1200 ml800 – 1200 ml: varf omoplat, sp. : varf omoplat, sp. Traube Traube

1700 ml1700 ml: spina scapulei: spina scapulei

2 l2 l: ant. sp II i.c., deplasare mediastin: ant. sp II i.c., deplasare mediastin

Ex. radiologicEx. radiologic

Radiografia toracica: frontala, laterala, oblicRadiografia toracica: frontala, laterala, oblic– 75 ml :obliterarea sinusului costofrenic post;75 ml :obliterarea sinusului costofrenic post;– 175 ml: obliterarea sinusului costofrenic lateral175 ml: obliterarea sinusului costofrenic lateral– 1000ml: ant coasta a IV-a1000ml: ant coasta a IV-a– masive : hemitorace ,deplaseaza mediastinulmasive : hemitorace ,deplaseaza mediastinul– In decubit: > 175 ml lichid In decubit: > 175 ml lichid

mici: grosime 1,5 cmmici: grosime 1,5 cm

moderate: 1,5 – 4,5 cmmoderate: 1,5 – 4,5 cm

mari > 4,5 cmmari > 4,5 cm

• Vasele pl sunt vizi- bile prin opacitatea lichidiana

• Bronhogramele aeriene sunt absente

• P. mari deplaseaza mediastinul

COLECTIILE INCHISTATECOLECTIILE INCHISTATE

Interlobara: incidenta de profil: opacitate Interlobara: incidenta de profil: opacitate fuziforma oblica sus/jos - ext/intfuziforma oblica sus/jos - ext/int

Diafragmatica : >2cm de bula de aer a SDiafragmatica : >2cm de bula de aer a S

Mediastinala : supra si infrahilar, ant si Mediastinala : supra si infrahilar, ant si postpost

• suprafata opacitatii este suprafata opacitatii este netedaneteda

• unghiurile interfetei intre unghiurile interfetei intre opac. pleurala si perete opac. pleurala si perete toracic sunt obtuzetoracic sunt obtuze

• continutul este omogen

colectii inchistatecolectii inchistate

ghidaj toracentezaghidaj toracenteza

ECOGRAFIA TORACICA

TOMOGRAFIA COMPUTERIZATA TORACICA

• Dg cant mici de lichid pleural

• Masoara grosimea pleurei

• Distinge empiemul de abcesul pulmonar

• Localizeaza si caracterizeaza compozitia lichide pl.

• Identifica fistule bronho pleurale periferice

• Pneumotorax mic

• Procese pulmonare subiacente

RMNRMN Diagnosticul lichidelor pleuraleDiagnosticul lichidelor pleurale Caracterizeaza continutul lichidelorCaracterizeaza continutul lichidelor Diagnosticul tumorilor pleuraleDiagnosticul tumorilor pleurale Invazia perete toracicInvazia perete toracic

TORACENTEZATORACENTEZA Diagnostica :lichid >1cm RxDiagnostica :lichid >1cm RxEvacuatorie (necesitate);Evacuatorie (necesitate);- dispnee- dispnee

- tendinta la inchistare- tendinta la inchistare- spatiul II i.c. anterior- spatiul II i.c. anterior

• hematom

• pneumotorax

•hemotorax,empiem

• punctia ficat,splina

• embolia gazoasa

EXAMENUL MACROSCOPIC

Ex. biochimic al lichiduluiEx. biochimic al lichidului

Criteriile Light: prot pl/prot ser>0,5Criteriile Light: prot pl/prot ser>0,5

LDH pl/ LDH ser >0,6LDH pl/ LDH ser >0,6

LDH pl>2/3 LDH serLDH pl>2/3 LDH ser

Prot pleurale : 3g/dl (1016) - pseudoexudat:Prot pleurale : 3g/dl (1016) - pseudoexudat:

- colest pl > 45mg/dl; - colest pl > 45mg/dl;

- col pl/col ser >0,3- col pl/col ser >0,3

- gradient prot serice - prot pl <3.1g/dl- gradient prot serice - prot pl <3.1g/dl

- Gradient alb serica – alb pl <1,2 mg/dl - Gradient alb serica – alb pl <1,2 mg/dl

E X U D A T

Glucoza Glucoza

- 40 mg/dl: infectii, neoplasme- 40 mg/dl: infectii, neoplasme

- 20 mg/dl: artrita reumatoida, LED- 20 mg/dl: artrita reumatoida, LED

AmilazeAmilaze

- pancreatita acuta, cronica- pancreatita acuta, cronica

- ruptura de esofag- ruptura de esofag

- pleurezii maligne- pleurezii maligne

- rar: pneumonii, sarcina ect. rupta- rar: pneumonii, sarcina ect. rupta

pH pH

- <7,3 – drenaj chirurgical al spatiului pleural- <7,3 – drenaj chirurgical al spatiului pleural

Ex. citologicEx. citologic

Hematii: - serosanguinolent 5000-10000/mmHematii: - serosanguinolent 5000-10000/mm33

- hemoragic: >100000/mm- hemoragic: >100000/mm33

-- accident punctie (col Wright) accident punctie (col Wright) - neoplasm, embolie pl, traumatisme- neoplasm, embolie pl, traumatisme

Leucocite - Leucocite - Neutrofile:Neutrofile: infectii pleurale (empiem) infectii pleurale (empiem) Insuf cardiaca: emb. pulmonaraInsuf cardiaca: emb. pulmonara

- - Limfocite Limfocite (>50%) TBC, neoplasme(>50%) TBC, neoplasme - - EozinofileEozinofile (>10%): aer sau sange, infectii (>10%): aer sau sange, infectii fungice sau parazitare, medicamente, fungice sau parazitare, medicamente,

EP, EP, parapneumoniceparapneumonice - - PlasmocitePlasmocite: mielom: mielom - - Cel mezotCel mezot : exclude TBC, : exclude TBC, cel. neoplazicecel. neoplazice

Ex. bacteriologicEx. bacteriologic

Frotiu : colorat Gram, Ziehl –NielsenFrotiu : colorat Gram, Ziehl –Nielsen

Culturi: aerobe, anaerobe, speciale:Lowenstein-Culturi: aerobe, anaerobe, speciale:Lowenstein-Jensen, Middlebrook 7H10 (COJensen, Middlebrook 7H10 (CO22).).

Teste suplimentareTeste suplimentare

Celule lupiceCelule lupice

Complementul Complementul

Lipidele : trigliceride > 110 mg/dlLipidele : trigliceride > 110 mg/dl

colesterolcolesterol

Biopsia pleuralaBiopsia pleurala

Citologie: 50-80% TBC, 40-75% neoplasmCitologie: 50-80% TBC, 40-75% neoplasm

Culturi : 90-95% TBCCulturi : 90-95% TBC

TRANSUDATE

• Insuficienta cardiaca ( pro BNP >1500 pg/ml)

• Ciroza (hidrotorax hepatic: 5% din cirotici cu ascita :

• Embolia pulmonara (infarct pulmonar);

• Sindromul nefrotic

• Mixedem : ascita,revarsat pericardic, revarsat pleural

• Urinotorax (rar)

• Sd. Meigs

• Atelectazia pulmonara

• Dializa peritoneala• Obstructia venei cave superioare

EXUDATE PLEURALEEXUDATE PLEURALE

NeoplasmeNeoplasme- metastaze- metastaze- mezoteliom- mezoteliom

InfectiiInfectii- bacteriene- bacteriene- TBC- TBC- fungice- fungice- virale- virale

- parazitare- parazitareEmbolie pulmonaraEmbolie pulmonaraPost bypass coronarianPost bypass coronarianExpunere la azbestExpunere la azbestHiperstimulare ovarianaHiperstimulare ovarianaSd unghiilor galbeneSd unghiilor galbeneUremia, Uremia, SarcoidozaSarcoidozaPost iradiere, Post iradiere, Sd. post lez cardiaceSd. post lez cardiace

Boli gastrointestinaleBoli gastrointestinale- perforatia esofagului- perforatia esofagului- boli pancreatice- boli pancreatice- abcese intraabdominale- abcese intraabdominale- hernia diafragmatica- hernia diafragmatica- post scleroterapie varice esofag- post scleroterapie varice esofag- dupa chir. abd, transpl. hepatic- dupa chir. abd, transpl. hepaticBoli de colagenBoli de colagen- artrita reumatoida- artrita reumatoida- LED- LED- medicamente ce induc LED- medicamente ce induc LED- limfadenopatia imunoblastica- limfadenopatia imunoblastica- Sd. Sjogren- Sd. Sjogren- Granulomatoza Wegener- Granulomatoza Wegener- Sd. Churg-Strauss- Sd. Churg-StraussMedicamenteMedicamente- nitrofurantoin- nitrofurantoin- methisergyde- methisergyde- bromcriptina- bromcriptina- amiodarona, procarbazina.- amiodarona, procarbazina.

90%: rezultatul a 5 boli:

- 36% Insuficienta cardiaca;

- 22% Pneumonia;

- 14% Neoplasmele;

- 11% Embolism pulmonar;

- 7% Afectiuni virale.

Pleurezia tuberculoasaPleurezia tuberculoasa

Cea mai frecventa cauza de exudat pl.Cea mai frecventa cauza de exudat pl.

Reactie de hipersensibilitate a spatiului pl. la proteinele Reactie de hipersensibilitate a spatiului pl. la proteinele

tuberculoase (mec. imunoalergic - fenomen Koch)tuberculoase (mec. imunoalergic - fenomen Koch)

Inf pulmonara sau gg. traheobronsiciInf pulmonara sau gg. traheobronsici

Raspandirea inflmatiei pulmonare sau penetrarea BK in sp. pl.Raspandirea inflmatiei pulmonare sau penetrarea BK in sp. pl.

Clinic: febra, scadere ponderala, dispnee, durere pleuriticaClinic: febra, scadere ponderala, dispnee, durere pleuritica

Ex. lichid: exudat uneori hemoragic, prot >50%din cele serice, Ex. lichid: exudat uneori hemoragic, prot >50%din cele serice,

glucoza <60mg/dl, pH < 7,2, Leuc: 500-6500/glucoza <60mg/dl, pH < 7,2, Leuc: 500-6500/μμL cu PMN initialL cu PMN initial

Ex. lichid: adenosin deaminaza>45 UI/l, Ex. lichid: adenosin deaminaza>45 UI/l, γγ interferon >140pg/ml, interferon >140pg/ml,

PCR pt ADN TBC pozitiv, limfocite miciPCR pt ADN TBC pozitiv, limfocite mici

Pleurezia tuberculoasaPleurezia tuberculoasa

Dg. culturi lichid pleural (44%), ex. citologic si Dg. culturi lichid pleural (44%), ex. citologic si culturi biopsie pleurala (79-90%), toracoscopieculturi biopsie pleurala (79-90%), toracoscopie

Empiem pleural : complicatie mai rara, ruptura Empiem pleural : complicatie mai rara, ruptura cavernelor in spatiul pleural cavernelor in spatiul pleural

Fistula bronho-pleurala – hidropneumotoraxFistula bronho-pleurala – hidropneumotorax

Lichid pleural purulent cu numar crescut de Lichid pleural purulent cu numar crescut de limfocitelimfocite

Frotiu si culturile l. pleural, de obicei +Frotiu si culturile l. pleural, de obicei +

Drenaj pleural, fibroza pleurala, decorticare Drenaj pleural, fibroza pleurala, decorticare

TUBERCULOSTATICE DE PRIMA LINIE

MedicamentMedicament Zilnic (5-7/7)Zilnic (5-7/7) Intermitent 2/7- 3/7Intermitent 2/7- 3/7

ISONIAZIDA (HIN)ISONIAZIDA (HIN) 5 mg/Kg5 mg/Kg,,300mg300mg 15mg/kg, 900mg15mg/kg, 900mg

RIFAMPICINARIFAMPICINA

(RIF)(RIF)

10mg/kg,600mg10mg/kg,600mg 10mg/kg, 600mg10mg/kg, 600mg

RIFABUTINARIFABUTINA 5mg/kg, 300mg5mg/kg, 300mg 5mg/kg,300mg5mg/kg,300mg

PYRAZINAMIDA PYRAZINAMIDA (PZN)(PZN)

20-25mg/kg 20-25mg/kg (max - 2g)(max - 2g)

30 – 40 mg/Kg max- 30 – 40 mg/Kg max- 3g3g

ETHAMBUTOL ETHAMBUTOL (EMB)(EMB)

15 -20mg/kg15 -20mg/kg 25 – 30 mg/kg25 – 30 mg/kg

FAZA INITIALA : HIN+RIF+PZN+EMB (5/7) - 2 luni sau 5/7 2saptamani si 2-3/7 – 6 saptamani;FAZA DE INTRETINERE: HIN +RIF (2-3/7)- 4 luni; Corticoterapie (discutabila): 40 mg/zi - 7 zile, scade treptat

EXUDATE PARAPNEUNONICEEXUDATE PARAPNEUNONICE

40% din pneumonii- exudate parapneumonice40% din pneumonii- exudate parapneumonice

3 categorii:3 categorii:

- - simple (necomplicatesimple (necomplicate)-exudat liber, steril ,)-exudat liber, steril ,

se rezolva cu tratamentul AB al pneumonieise rezolva cu tratamentul AB al pneumoniei

- - empiemempiem : infectia sp. pleural ( germeni – : infectia sp. pleural ( germeni –

frotiu sau culturi – drenaj pleuralfrotiu sau culturi – drenaj pleural

- - complicate:complicate: cantitativ mai mari cu manifes- cantitativ mai mari cu manifes-

tari evidente de inflamtie: glucoza ↓, pH↓, tari evidente de inflamtie: glucoza ↓, pH↓,

Inchistare – “ coaja” fibropurulenta – drenaj (?}Inchistare – “ coaja” fibropurulenta – drenaj (?}

Infectii pulmonare: pneumonii, abces pl, bronsi-Infectii pulmonare: pneumonii, abces pl, bronsi-ectazii, ectazii,

Empiem :35% nosocomiale: anaerobi, Gr (- ), Empiem :35% nosocomiale: anaerobi, Gr (- ), stafilococstafilococ

AerobiAerobi: febra, expectoratie, durere pleuritica, : febra, expectoratie, durere pleuritica, leucocitoza leucocitoza

AnaerobeAnaerobe: subacut, scadere ponderala, : subacut, scadere ponderala, leucocitoza minima, anemie, cond. de leucocitoza minima, anemie, cond. de aspiratieaspiratie

EXUDATE PARAPNEUMONICE

REVARSAT PARAPNEUMONICREVARSAT PARAPNEUMONIC

Rx : - l. inchistat (decubit lateral, CT, EcografieRx : - l. inchistat (decubit lateral, CT, Ecografie

Toracenteza caracteristici: Toracenteza caracteristici: - aspect macroscopic (serocitrin, puroi)- aspect macroscopic (serocitrin, puroi)- biochimic: glucoza, pH;- biochimic: glucoza, pH;- citologie :PMN, eozinofile- citologie :PMN, eozinofile- ex. bacteriologic: frotiu, culturi- ex. bacteriologic: frotiu, culturi

Prognostic prost:Prognostic prost:

- lichid inchistat- lichid inchistat

- pH <7,2, glucoza <3,3mmol/l (<60mg/dl)- pH <7,2, glucoza <3,3mmol/l (<60mg/dl)

- frotiu sau culturi pozitive- frotiu sau culturi pozitive

- puroi- puroi

TORACOSTOMIA IN PLEUREZII PARAPNEUMONICE

• Criterii radiologice:

- lichid pleural inchistat;

- lichid pleural >1/2 hemitorace;

- imagine hidro-aerica pleurala.

• Criterii microbiologice:

- lichid purulent;

- frotiu pozitiv pt.microorganisme;

- culturi pozitive ale lichidului pleural.

• Criterii chimice:

- pH pleural<7,2

- glucoza pleurala<60mg/dl, LDH > 1000 U/ml

DRENAJ PLEURALDRENAJ PLEURAL

TORACOSTOMIATORACOSTOMIA - tub dren sp 5-6 LAM- - tub dren sp 5-6 LAM- drenaj (sifonaj apa)drenaj (sifonaj apa)

- Trombolitice: streptokinaza 250.000U, - Trombolitice: streptokinaza 250.000U, urokinaza -100.000 U in 50-100 ml sol urokinaza -100.000 U in 50-100 ml sol salina.salina.

- Drenaj <100ml/zi – se scoate tubul;- Drenaj <100ml/zi – se scoate tubul;

ToracoscopiaToracoscopia - ruperea aderentelor - ruperea aderentelor

ToracotomiaToracotomia - decorticarea pleurala - decorticarea pleurala

Pleurezii viralePleurezii virale

exudate fara etiologie (20%)exudate fara etiologie (20%)

se rezolva spontan, fara sechelese rezolva spontan, fara sechele

Pleurezia post embolie pulmonaraPleurezia post embolie pulmonara

Conditii favorizanteConditii favorizante

Clinic: dispneeClinic: dispnee

Exudat sau transudat : eozinofile, cel mezotelialeExudat sau transudat : eozinofile, cel mezoteliale

CT spirala, Arteriografia pulmonaraCT spirala, Arteriografia pulmonara

Trat. anticoagulantTrat. anticoagulant

PLEUREZII DIN BOLI DE COLAGENPLEUREZII DIN BOLI DE COLAGEN

ARTRITA REUMATOIDAARTRITA REUMATOIDA

- - revarsat pl cronic (psudochilotorax)revarsat pl cronic (psudochilotorax)

- exudat, glucoza <20mg/dl, colesterol- exudat, glucoza <20mg/dl, colesterol

- localizarea nodulilor reumatoizi in pleura- localizarea nodulilor reumatoizi in pleura

LESLES

- pleurezie bilaterala recidivanta, pericardita- pleurezie bilaterala recidivanta, pericardita

- FAN, Ac-AND(ser), cel lupice (l.pleural)- FAN, Ac-AND(ser), cel lupice (l.pleural)

POLIARTERITA NODOASAPOLIARTERITA NODOASA

- fibroza reticulara, noduli, infarct pulmonar, - fibroza reticulara, noduli, infarct pulmonar, infiltrate, revarsat pleural.infiltrate, revarsat pleural.

- episoade de astm- episoade de astm

Pleurezia neoplazicaPleurezia neoplazica

Cauza frecventa de exudat la persoane >60 aniCauza frecventa de exudat la persoane >60 ani75%: carcinom pulmonar, mamar, limfoame75%: carcinom pulmonar, mamar, limfoameCaracteristici: aspect hemoragic, refacere rapida Caracteristici: aspect hemoragic, refacere rapida (<1 saptamana)(<1 saptamana)Ex lichid: exudat, glucoza scazuta, ex. Ex lichid: exudat, glucoza scazuta, ex. citologic :cel neoplazicecitologic :cel neoplaziceToracosopieToracosopie Biopsie pleuralaBiopsie pleuralaTratament simptomatic: drenaj pleuralTratament simptomatic: drenaj pleuralPleurodezie: - Talc: RA - febra, insuf.resp.Pleurodezie: - Talc: RA - febra, insuf.resp.

(Tub, toracoscopie) - Doxiciclina, (Tub, toracoscopie) - Doxiciclina, - Bleomicina ; - Bleomicina ;

- - ▪ ▪ Cateter pleural cronic - drenaj in container Cateter pleural cronic - drenaj in container

vacuum (Denver PleurX) vacuum (Denver PleurX)

▪ ▪ Sunt pleuroperitoneal;Sunt pleuroperitoneal;

▪ ▪ Pleurectomie sau ablatie pleurala Pleurectomie sau ablatie pleurala (pleurodezie(pleurodezie

ineficienta) - chirurgie toracica.ineficienta) - chirurgie toracica.

▪ ▪ Chemoterapie si radioterapie: limfom, carcinom Chemoterapie si radioterapie: limfom, carcinom

pl.cu cel micipl.cu cel mici

Mezoteliom Mezoteliom

- - Tumora primara cu punct de plecare cel mezo-Tumora primara cu punct de plecare cel mezo-

telialeteliale

MEZOTELOPMMEZOTELOPM

80% -T. pleurale, 20% T. peritoneale80% -T. pleurale, 20% T. peritoneale

¾ - M. difuze (maligne), ¼ M localizate ¾ - M. difuze (maligne), ¼ M localizate (benigne)(benigne)

60-80% M. maligne expunere la asbest – 60-80% M. maligne expunere la asbest – 20-40 ani anterior20-40 ani anterior

Debutul simptomelor la varsta de 60 aniDebutul simptomelor la varsta de 60 ani

Dispnee , durere toracica, scadere Dispnee , durere toracica, scadere ponderalaponderala

Clinic: matitate, MV diminuat, hipocratismClinic: matitate, MV diminuat, hipocratism

- L pleural : exudat hemoragic, (hialuronidaza), toracoscopie, biopsie pleurala; - forma histologica epiteliala si fibroasa (sarcom)

- Rx : ingrosare pleurala neregulata, revarsat pleural unilateral,; scolioza spre leziunea pleurala

Evolutie locala: pericard, mediastin, pleura contralaterala, perete toracic, meta abdominale

- Sd vena cava sup, Sd. Horner, manifest. para neoplazice:trombocitoza, A. hemolitica, Trb migratorie

- Mezotelina serica - marker tumoral dg si de monitorizare;

-PET – distinge formele benigne de cele maligne;

Neoplasm incurabil;

- Chirurgie, Radioterapie, Chemoterapie (fara succes)

-Paleativ : durere (radioterapie), analgetice opioide, cateter

epidural;

- Drenaj pleural

- Pleurodesie, pleurectomie

- Supravietuire: 4-16 luni.

ChilotoraxChilotorax

Acumularea limfei in spatiul pleuralAcumularea limfei in spatiul pleural

Etiologie: - leziuni traumatice ale canalului toracicEtiologie: - leziuni traumatice ale canalului toracic

- - tumori mediastinaletumori mediastinale

- - malformatii ale canalului toracic (fistule)malformatii ale canalului toracic (fistule)

- tromboza venei subclaviculare stg- tromboza venei subclaviculare stg

- anevrismul aortei toracice- anevrismul aortei toracice

Revarsat pleural masiv – dispneeRevarsat pleural masiv – dispnee

Ex.lichid: lactescent, trigliceride >110mg/dl (1,2 mmol/l)Ex.lichid: lactescent, trigliceride >110mg/dl (1,2 mmol/l)

Limfangiograma, CT toracicLimfangiograma, CT toracic

Tratament conservator: aliment. parenterala, nu toracen-Tratament conservator: aliment. parenterala, nu toracen-teze repetate (denutritie, imunodepresie); octreotideteze repetate (denutritie, imunodepresie); octreotide

Sunt pleuroperitoneal, ligatura chirurgicala canal limfaticSunt pleuroperitoneal, ligatura chirurgicala canal limfatic

S. UNGHIILOR GALBENE

• exudat pleural cronic

• limfedem

• unghii galbene distrofice

• tulburari in drenajul limfatic

HEMOTORAXHEMOTORAX

EtiologieEtiologie

- traumatisme- traumatisme

- ruptura vaselor toracice ( ruptura de aorta)- ruptura vaselor toracice ( ruptura de aorta)

- tumori mediastinale- tumori mediastinale

Lichid pleural: hemoragic Ht > 50% din sg perifericLichid pleural: hemoragic Ht > 50% din sg periferic

Tub de dren : hemoragie > 200 ml/h chirurgie Tub de dren : hemoragie > 200 ml/h chirurgie

toracica (sutura vasculara)toracica (sutura vasculara)

PNEUMOTORAXPNEUMOTORAX

Patrunderea aerului in spatiul pleuralPatrunderea aerului in spatiul pleural

Generalizat, localizatGeneralizat, localizat

Deschis, inchis, valvular (in tensiune)- Deschis, inchis, valvular (in tensiune)- presiune pozitiva intrapleurala in tot ciclul presiune pozitiva intrapleurala in tot ciclul respiratorrespirator

Forme: Forme: P. spontan primarP. spontan primar (fara lez pl ant, (fara lez pl ant, fara traumatisme); fara traumatisme); P. spontan secundarP. spontan secundar (lez (lez pl ant); pl ant); P. traumaticP. traumatic (lez toracice penetrante (lez toracice penetrante sau nepanetrante) sau nepanetrante) P. in tensiuneP. in tensiune

Clinic: durere, dispnee; (sonotitate ↑, VV ↓, miscari Clinic: durere, dispnee; (sonotitate ↑, VV ↓, miscari resp.↓).resp.↓).

Oximetrie (hipoxemie,alcaloza), EKG (P.stg)Oximetrie (hipoxemie,alcaloza), EKG (P.stg)

Rx pl: transparenta fara desen brohovascular intre Rx pl: transparenta fara desen brohovascular intre plaman si perete toracic, pleura viscerala vizibilaplaman si perete toracic, pleura viscerala vizibila

• • P. spontan primar:P. spontan primar:

- ruptura chistelor aeriene apicale - ruptura chistelor aeriene apicale

- fumatori- fumatori

- ½ au recidive- ½ au recidive

- aspiratia simpla ac - valve Heimlich, - aspiratia simpla ac - valve Heimlich,

- toracoscopia: capsarea chistelor, pleurodezie- toracoscopia: capsarea chistelor, pleurodezie

• P. spontan secundar:P. spontan secundar:- BPOC, astm, fibroza pl, pneumonii, abcese, - BPOC, astm, fibroza pl, pneumonii, abcese,

neoplasmneoplasm

- insuficienta respiratorie frecventa- insuficienta respiratorie frecventa

- toracostomie si instilarea agent sclerozant- toracostomie si instilarea agent sclerozant

- persistenta aer (> 3 zile toracostomie), - persistenta aer (> 3 zile toracostomie), toracoscopie cu rezectia lez. pulmonare si ple- toracoscopie cu rezectia lez. pulmonare si ple- urodezie urodezie

•• P. traumaticP. traumatic

-- traumatisme toracice ne/penetrante traumatisme toracice ne/penetrante

- toracostomie, aspirarea aerului- toracostomie, aspirarea aerului

- hemopneumotorax: 2 tuburi: sup. aer, inf. sange- hemopneumotorax: 2 tuburi: sup. aer, inf. sange

•• P. iatrogenP. iatrogen

- toracenteza,aspirarea transtoracica, - toracenteza,aspirarea transtoracica, cateter venos central, ventilatia cateter venos central, ventilatia

mecanica mecanica - obsevatia, O- obsevatia, O22, toracostomia., toracostomia.

• • P. in tensiuneP. in tensiune - Clinic: dispnee, anxietate, cianoza, FR- Clinic: dispnee, anxietate, cianoza, FR↑↑

FCFC↑, hTA↑, hTA, emf.mediastinal, emf.mediastinal - Rx: hemitorace largit,- Rx: hemitorace largit, aplatizarea diafragm, coborarea aplatizarea diafragm, coborarea

ficatuluificatului deplasarea mediastinului (cord)deplasarea mediastinului (cord)

- Urgenta medicala: insuf respiratorie, sincopa - Urgenta medicala: insuf respiratorie, sincopa

(debit cardiac redus)(debit cardiac redus)

- Ac in sp. i.c. II anterior , tub toracostomie- Ac in sp. i.c. II anterior , tub toracostomie

Complicatii:

- aer in pleura ( lez pulmonara, cateter)

- absenta reexpansiunii pl: obstructie bronsica,

incorsetare pl;

- EPA - reexpansiune (colaps pl >2zile);